Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.HEALTH QUESTIONNAIREDear patients! We kindly ask you to fill out the questionnaire, which will provide us with a better insight into your overall health condition and thus enable us to adjust dental care accordingly. All fields marked with * are mandatory.Name and Surname *Gender *MaleFemaleDate of Birth *Address *Postal Code *City *Country *Email *Phone Number *Occupation / EducationName and Surname of Personal DoctorDoctor's Phone Number The data is confidential and serves DMC PRAPROTNIK d.o.o. only for medical purposes. DENTAL QUESTIONS:1. Do you believe that your teeth have any impact on your health? *YesNo2. Are you satisfied with the appearance of your teeth? *YesNo3. Have you had any past negative experiences with a dentist? *YesNo4. Do you have difficulties with chewing food? *YesNo5. Have you ever had any injuries to your face, jaw, or teeth? *YesNo6. Do you experience frequent headaches? *YesNo7.Have you had a toothache recently? *YesNo8. Which pain reliever do you use most often?9. Do your gums bleed while brushing? *YesNo10. Do you have sensitive teeth (they hurt when exposed to hot or cold)?Ali imate občutljive zobe (vas skelijo)? *YesNo11. Do you have difficulties opening your mouth (jaw joint clicking or popping)? *YesNo12. How often do you brush your teeth? *13. Do you use any additional oral hygiene tools? *YesNoWhich additional oral hygiene tool are you using?Dental flossInterdental brushTongue scraperTongue scraperOtherOTHER HEALTH QUESTIONS::1. Have you been hospitalized or seriously ill in the past two years? *YesNo2. Have you taken any medications in the last year? If so, which ones? *YesNoa.) If so, which ones?3. Have you experienced complications with local or general anesthesia? *YesNo4. Are you allergic to any medications or materials? *YesNoa.) What are you allergic to? *AspirinPenicilinLatexDental materialsLocal anestheticNalgesinNaklofenBrufenDiverinKetonalNaprosynOtherb.) To which other medication are you allergic?5. Do you have any other allergies? *YesNoa.) Which allergy do you have?6. Have you ever experienced blood clotting disorders? *YesNo7. Have you received radiation therapy to the head or neck? *YesNo8. Do you have any autoimmune diseases? *YesNoa.) Which autoimmune disease do you have? *9. Have you ever received a blood transfusion? *YesNo10. Do you use tobacco and related products (cigarettes, snus, electronic cigarettes, vapes, etc.)? *YesNoa.) Which tobacco and related products do you use?b.) How many per day? c.) How many years?11. Have you stopped using tobacco and related products? *YesNoa.) When did you stop?12. Have you ever been treated with bisphosphonates for osteoporosis? *YesNo13. Do you have any electronic devices implanted (e.g., pacemaker)? *YesNoa.) Which electronic device do you have?14. Mark the diseases and conditions you have or have had in the past.Heart valve defectsArrhythmiaArtificial heart valveInfective EndocarditisCongenital heart defectsHigh blood pressureStrokeHeart attackRheumatoid arthritisAnemiaOsteoporosisLeukemiaEnlarged lymph nodesAsthmaChronic coughRespiratory diseasesTuberculosisDiabetesSinusitisSexually transmitted diseasesMalignomaGlaucomaOral mucosal fungal infectionsJaundiceThyroid diseasesHepatitisEpilepsy (seizures)Epilepsy (seizures)Psychiatric treatmentDigestive ulcersOthera.) What other disease do you have?15. Do you have any contagious diseases (e.g., herpes, hepatitis, AIDS)? *YesNoWhat infectious disease do you have? *16. Have you been exposed to the AIDS virus due to risky behaviors? *YesNo17. Are you pregnant? *YesNoa.) When is the expected due date? 18. Do you have any other diseases or conditions not mentioned in the questionnaire? *YesNoa.) What disease do you have?COMPLETED BY THERAPIST: Questionnaire reviewed by responsible therapistYESNOPatient's or guardian's Signature: * Clear Signature Pošlji
